Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE:01|01|2014 POLICY LAST UPDATED: 10|04|2025

OVERVIEW Visual acuity refers to the sharpness or clarity of vision, measured as the ability to distinguish letters or other images of various sizes at a fixed distance, usually with a Snellen chart.

NOTE: This policy applies to members who do NOT have preventive services as provided under the Affordable Care Act (ACA). See the Preventive Services for Commercial policy for those members who have preventive services under ACA.

MEDICAL CRITERIA None applicable

PRIOR AUTHORIZATION None applicable

POLICY STATEMENT Commercial Products Visual acuity testing (99173) is a covered, separately reimbursable service when performed in conjunction with a preventive medicine service code (99382, 99383, 99392, 99393) for patients aged 3-5 years. For all other ages, visual acuity screening is considered integral to an evaluation and management service or a preventive medicine examination and is not separately reimbursed.

Instrument-based ocular screening (e.g., photo screening, automated-refraction), bilateral (99174 and 99177) are covered and a separately reimbursable service. The services are covered for twice per year for children ages 0-11 months and once per year for children 1-5. For services rendered on children greater than age 5, the codes are covered but not separately reimbursed.

Note: Instrument based ocular screening (99174 and 99177) should not be filed on the same day as visual acuity testing (99173).

COVERAGE Commercial Products Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable medical benefits/coverage.

BACKGROUND Visual acuity refers to the clarity or clearness of the vision, a measure of how well a person sees. Visual acuity testing is used to determine how well a person can see at various distances using a Snellen chart. The Snellen chart is the familiar eye test with block letters that decrease in size corresponding to the distance at which the line of letters is normally visible.
Visual acuity testing is normally performed as part of a pediatric preventive (well-child) visit. When acuity is measured as part of a general ophthalmological service or an evaluation/management service of the eye, it is a diagnostic examination and not a screening test and should be reported using the appropriate Payment Policy | Visual Screening for Children Ages 0-5 Years

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

ophthalmological service code (92002, 92004, 92012, 92014, 92081, 92082, or 92083) or evaluation and management codes (99201 to 99215).
Ocular photoscreening is based on the principle of photorefraction in which the refractive state of the eye is assessed via the pattern of light reflected through the pupil. The images can then be analyzed based on the position of the corneal light reflex, as well as the overall reflection of light from the fundus, which provides information on the child’s fixation pattern and the presence or absence of strabismus. Patients are photographed in a darkened room while looking at the camera. The photographs can be sent to a central laboratory for analysis, either by ophthalmologists or specifically trained personnel. Results are typically graded as pass, fail, or repeat photo screening.

CODING Commercial Products The following codes are covered and separately reimbursed for ages 0-5 and not separately reimbursed for ages greater than 5:

99173 Screening test of visual acuity, quantitative, bilateral
99174 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with remote analysis and report 99177 Instrument-based ocular screening (e.g., photoscreening, automated-refraction), bilateral; with on-site analysis

RELATED POLICIES Preventive Services for Commercial

PUBLISHED Provider Update, November 2025 Provider Update, December 2023 Provider Update, March 2020 Provider Update, April 2018 Provider Update, March 2017 Provider Update, March 2016 Provider Update, January 2016

i

ii

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.